Areas Being Affected?

Neuropathy Program Protocol

Patient Name: ______

____ times _____ for ______

____ times _____ for ______

____ times _____ for ______

____ times _____ for ______

____ times _____ for ______

____ times _____ for ______

Total Visits: ______

Areas Being Affected?

Neuropathy Program Protocol

*Staff must initial everything they complete.

12-Week Neuropathy Program © 2013 Club Reduce®

12-WEEK NEUROPATHY PROGRAM EVALUATIONS

Patient Name: ______Age: ______Height:______Anticipated Start Date of Program: ______

12-Week Neuropathy Program © 2013 Club Reduce®

12-WEEK NEUROPATHY PROGRAM

PRODUCTS

Patient Name: ______Date: ___/___/___

I have checked off (ü) the products above and I verify that all of these products are included in this packet:

By signing this, I acknowledge that I have been given all of the products that I need for the duration of this program. If I choose to take more supplements on some days, I know that I will have to purchase more if I run out.

______

Signed Date

(Patient Signature)

______

Signed Date

(Employee Signature)

12-WEEK NEUROPATHY PROGRAM CONTRACT

Your signature below indicates that you understand the following: All sales are final. You are solely responsible for any treatment rendered in this office. All services rendered to you are charged directly to you, and you are personally responsible for payment. This office does not accept insurance of any kind. (Please advise us immediately if you are a Medicare patient, as we do not treat Medicare patients for services covered by Medicare.)

If you purchase this entire package, a discount may be given. You understanding that if the entire program isn’t completed, the discount becomes void and the items and services rendered will be charged at the rates listed above.

If you move from the area before your program is completed, we will issue a store credit up to 3 months after the purchase date. The store credit will be good for any services not yet rendered that were scheduled to be performed after the date of your move. The amount of the store credit for those services will be given at the rate that was originally charged. If a discount was given, the credit will reflect that. All product sales are final and no refunds will be given, as you can and should continue to take the products.

When you are scheduled for a service or appointment, a room and employee are reserved for you. If you don’t show up, the employee member and room assigned to you are not utilized, and resources are wasted. Therefore, if we do not have a 48-hour notice of cancellation for an appointment, you may still be charged for that service as if you had been here.

You authorize the staff to perform any necessary services needed during treatment.

You understand the above information and guarantee that this form was completed correctly to the best of your knowledge and understand it is your responsibility to inform this office of any changes to the information you have provided.

Your signature indicates that you understand these policies and that you will comply with the above requirements.

______

Patient Name Printed Date

______

Patient Signature Date

______

Employee Signature Date

Checklist for Explaining a Neuropathy Program

DATE:______PERSON EXPLAINING PROGRAM:______

PATIENT:______

INVENTORY

_____Complete product Inventory with patient

_____Have patient sign product inventory

_____Have Wellness Coach sign product inventory

_____Emphasize to patient that the program includes ALL SUPPLEMENTS needed for the program. If

the patient runs out because they use more than allotted or share them, they can purchase more

from our clinic or online. They will NOT be given any more for free.

WEEKLY TREATMENTS/PROCEDURES

_____Explain each weekly visit procedure

_____Let them know they MUST bring their food journal each week (NO EXCEPTIONS!)

NUTRITION PROGRAM

_____Review Food List

_____Calculate how much water they must drink each day

_____Review Structuring Your Diet

_____Review Detox

_____Review Healing Crisis

_____Review How to Take Your Supplements

_____Review Daily Food Log (Food/Supplement Instructions and How to record food eaten)

CLUB REDUCE MEMBERSHIP SITE AND SOCIAL MEDIA

_____Give tour of Club Reduce membership site

_____Invite them to follow us on Facebook, Twitter, Pinterest, and our Blog

_____Invite them to the next class (cooking class, yoga class, etc.)

_____Invite them to the Monday Support Group

______

EMPLOYEE SIGNATURE

Notes

______

Preferred Patient Referral Program

Each week in staff meeting we discuss our patients and how we can better serve them.

While all of our patients are important to us, some of our patients just make our work extra enjoyable!

You are one of those patients that we have singled out as “making our work extra enjoyable!”

We all look forward to your visits in our office, and quite frankly, we wish we had more patients JUST LIKE YOU!

Because of that, we have a “Preferred Patient Referral Program” implemented in our office called…

“We Want More Patients Like You!”

Here are some questions you might be asking:

What is Our Goal? To obtain more awesome patients that make our work enjoyable, like you do!

Why Would You Want to Participate? For every person that you refer that either attends one of our seminars or comes in for an evaluation, you’ll receive one of the following:

¨ $25.00 Coupon for Products or Services in our Office

Or

¨ Free Chocolate Nutritional Shake (Yes, you could also choose Strawberry, Orange or Vanilla)

Or

¨ Free SMT Session

Will This Be a Hassle for You to Participate in? No! Simply fill in the information on the back of this sheet with the names of the people that you think might be interested in some of our services. (You might not even be aware of all of the services we have available. Please see the back so you can see them all!)

Will We Be Bothering People You Refer? No! They will receive something in the mail…that’s all! All we need from you is the name and mailing address for the people you’d like to refer. (If you don’t have their address, we can search for it online.) We won’t call, email or bother your friends. We’ll simply send them something interesting in the mail. If they are interested, they’ll respond; if they aren’t, we won’t be contacting them by any other means!

How Many People Can You Refer? We’d love all the referrals you’d like to give! We’ve had some patients that have referred so many that they’ve had lots and lots of credit in our office for products and services. That makes us happy, you happy and your referred friends happy!

How Will You Know If Your Referrals Come in? We make a point to find out where every patient comes from, so we can thank you and get your referral bonuses to you!

Your Name: ______

At Lighthouse Health, we have many programs available such as:

Breakthrough Weight Loss Diabetes/Blood Sugar Issues Skin Care Programs

Kids Weight Loss Candida Body Wraps

Teen Weight Loss Fibromyalgia Neuropathy

Family Weight Loss Pain Relief Detoxification Programs

Personal Training Hormone Balancing Maintenance

We would love to send out some literature on some of these programs to your friends, family, co-workers, or any other acquaintance you can think of who might benefit from this information. Please list people you know you might have an interest in any of this information. Please use an additional sheet if needed.

Name ______

Address ______

City, State, Zip Code ______

Information to Send (Optional) ______

Name ______

Address ______

City, State, Zip Code ______

Information to Send (Optional) ______

Name ______

Address ______

City, State, Zip Code ______

Information to Send (Optional) ______

Name ______

Address ______

City, State, Zip Code ______

Information to Send (Optional) ______

12-Week Neuropathy Program © 2013 Club Reduce®